Procedures and prevention: the challenges of Choosing Wisely

- Kenny Lin, MD, MPH

A 55 year-old woman with chronic low back pain and symptomatic knee osteoarthritis asks your opinion about lumbar fusion surgery and some arthritis walking shoes she saw advertised on television. She is prescribed long-acting oxycodone and physical therapy for back pain, and her orthopedist recently began a series of hyaluronic acid injections for her knees. She is up-to-date on cervical and breast cancer screening, but also desires screening for ovarian cancer.

Next, you see this patient's husband, a 60 year-old man with stable coronary artery disease. He was recently hospitalized for an episode of chest pain, and although tests did not show a myocardial infarction, a cardiac catheterization found an 80% stenosis in the left anterior descending artery. He already takes a baby aspirin daily, but his cardiologist has advised adding clopidogrel and having a coronary stent placed. Last year, he quit smoking after going through a pack of cigarettes a day for 40 years, and he is interested in screening for lung cancer. Also, since his brother was diagnosed with colorectal cancer at age 50, he has undergone screening colonoscopies at ages 40, 45, 50, and 55. These have all been normal, and he wonders if it is necessary for him to continue having them every 5 years.

Although both of these patients are fictitious, they represent common clinical scenarios in family medicine that contain enormous potential for overdiagnosis and overtreatment. In the August 15 issue of American Family Physician, Drs. Roland Grad and Mark Ebell present this year's edition of the "Top POEMs Consistent with the Principles of the Choosing Wisely Campaign," which includes the following suggested clinical actions:

• In patients with chronic low back pain, do not recommend lumbar fusion over physical therapy for pain or disability.
• In patients with chronic noncancer pain, try to avoid the use of long-acting opioids because they are associated with a significantly increased risk of premature mortality.
• In patients with knee degenerative joint disease, do not recommend hyaluronic acid injections because they are only minimally better than sham injections in improving pain and function.
• In patients with documented knee OA, do not recommend specifically designed walking shoes because they are no more effective than typical walking shoes at relieving pain and improving function.
• In patients with chronic stable angina and at least 70% stenosis of one coronary artery, do not recommend PCI with optimal medical therapy over optimal medical therapy alone.
• In patients with, or at risk of, coronary artery disease, do not add clopidogrel (Plavix) to aspirin because it does not change the overall risk of death.

As with last year's Top POEMs list, questioning unnecessary procedures or non-beneficial treatments is an effective way to protect patients from harm. But it's important to take a critical approach to preventive care as well to avoid overscreening. For example, as Dr. Jennifer Middleton noted in a previous blog post, one high-profile screening test for ovarian cancer still has big gaps in the evidence regarding its effect on mortality. Drs. Grad and Ebell advise against screening for ovarian cancer and carefully weighing the risks and benefits of lung and colorectal cancer screening:

• In women at average risk, do not recommend screening for ovarian cancer because they are unlikely to experience any mortality benefit.
• In all patients deciding to screen for lung cancer with low-dose CT, discuss the significant risks of harm (3% mortality from invasive procedures after screening) compared with the large number needed to screen to prevent one death from lung cancer (308; 95% confidence interval, 201 to 787).
• In patients who have one first-degree relative with colorectal cancer, but have not developed the cancer by 55 years of age, advise them that their risk is similar to the risk of colorectal cancer in the general population.

It is challenging, and sometimes uncomfortable, to question long-accepted practices that feel like "old friends," AFP assistant medical editor Allen Shaughnessy wrote in a 2016 editorial. He suggested that clinicians keep in mind that the purpose of these evidence-based recommendations, and all of those from the Choosing Wisely campaign, is to improve care and reduce harm:

Every aspect of patient care—every word we say, every test or exam we perform, every treatment or procedure we employ—carries with it the possibility of harm as well as the opportunity for benefit. Although eliminating overuse is often perceived as a way of cutting medical costs, it is really about decreasing wasteful, unnecessary testing and treatment that offer only the potential of harm without the corresponding possibility of benefit. Sometimes, we need to leave our old friends behind.